Cancer Control Knowledge into Action WHO Guide for Effective Programmes ppt

More than 70% of all cancer deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent.But b

Diagnosis and Treatment

Knowledge into Action Cancer Control

WHO Guide for Effective Programmes

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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization

in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication However, the published material is being distributed without warranty of any kind, either expressed or implied The responsibility for the interpretation and use of the material lies with the reader In no event shall the World Health Organization be liable for damages arising from its use.

The Cancer Control – Diagnosis and Treatment module was produced under the direction of Catherine Le Galès-Camus (Former Assistant Director-General, Noncommunicable Diseases and Mental Health), Serge Resnikoff (Coordinator, Chronic Diseases Prevention and Management) and Cecilia Sepúlveda (Chronic Diseases Prevention and Management, coordinator of the overall series of modules)

Twalib Ngoma was the coordinator for this module and Cecilia Sepúlveda provided extensive editorial input

Editorial support was provided by Anthony Miller (scientific editor), Inés Salas (technical adviser) and Angela Haden (technical writer and editor) Proofreading was done

by Ann Morgan

The production of the module was coordinated by Maria Villanueva and Neeta Kumar.

Core contributions for the module were received from the following experts:

Baffour Awuah, Komfo Anokye Teaching Hospital, Ghana

Yasmin Bhurgri, Karachi Cancer Registry and Aga Khan University Karachi, Pakistan

Ian Magrath, International Network for Cancer Treatment and Research, Belgium

Luiz Figueiredo Mathias, National Cancer Institute, Brazil

M Krishnan Nair, Regional Cancer Centre, India

Twalib A Ngoma, Ocean Road Cancer Institute, United Republic of Tanzania

Eduardo Rosenblatt, International Atomic Energy Agency, Austria

The above contributors have signed a declaration indicating they have no conflicts of interest.

Valuable input, help and advice were received from a number of people in WHO headquarters throughout the production of the module: Caroline Allsopp, David Bramley, Raphặl Crettaz and Maryvonne Grisetti

Cancer experts worldwide, as well as technical staff in WHO headquarters and in WHO regional and country offices, also provided valuable input by making contributions and reviewing the module, and are listed in the Acknowledgements

Design and layout: L’IV Com Sàrl, Morges, Switzerland, based on a style developed by Reda Sadki, Paris, France.

Printed in Switzerland

More information about this publication can be obtained from:

Department of Chronic Diseases and Health Promotion

World Health Organization

CH-1211 Geneva 27, Switzerland

The production of this publication was made possible through the generous financial support of the National Cancer Institute (NCI), USA, and the National Cancer Institute (INCa), France We would also like to thank the Public Health Agency of Canada (PHAC), the National Cancer Center (NCC) of the Republic of Korea, the International Atomic Energy Agency (IAEA), and the International Union Against Cancer (UICC) for their financial support

Cancer is a leading cause of death globally The World Health Organization estimates that 7.6 million people died of cancer in 2005 and 84 million people will die in the next 10 years if action is not taken More than 70% of all cancer deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent.

But because of the wealth of available knowledge, all countries can, at some useful level, implement the four basic components of cancer control – prevention,

early detection, diagnosis and treatment, and palliative care – and thus avoid

and cure many cancers, as well as palliating the suffering

Cancer control: knowledge into action, WHO guide for effective programmes is

a series of six modules that provides practical advice for programme managers and policy-makers on how to advocate, plan and implement effective cancer control programmes, particularly in low- and middle-income countries

Cancer is to a large extent avoidable Many cancers

can be prevented Others can be detected early in their

development, treated and cured Even with late stage

cancer, the pain can be reduced, the progression of the

cancer slowed, and patients and their families helped

to cope.

Cancer Control Series

Introduction to the

Series overview

Knowledge into Action

Cancer Control

WHO Guide for Effective Programmes Prevention

A practical guide for programme managers on how to implement effective cancer prevention by controlling major avoidable cancer risk factors.

Early Detection

Knowledge into Action

Cancer Control

WHO Guide for Effective Programmes early detection

A practical guide for programme managers on how to implement effective early detection of major types of cancer that are amenable

to early diagnosis and screening

Diagnosis and

Treatment

Knowledge into Action

Cancer Control

WHO Guide for Effective Programmes diagnosis and treatment

A practical guide for programme managers on how to implement effective cancer diagnosis and treatment, particularly linked to early detection programmes or curable cancers

Palliative Care

Knowledge into Action

Cancer Control

WHO Guide for Effective Programmes Palliative care

A practical guide for programme managers on how to implement effective palliative care for cancer, with a particular focus on community-based care

Policy and

Advocacy

Knowledge into Action

Cancer Control

WHO Guide for Effective Programmes Policy and advocacy

A practical guide for medium level decision-makers and programme managers on how to advocate for policy development and effective programme implementation for cancer control

resolution on cancer prevention and control (WHA58.22), adopted

in May 2005, which calls on Member States to intensify action against cancer by developing and reinforcing cancer control

programmes It builds on National cancer control programmes:

policies and managerial guidelines and Preventing chronic diseases: a vital investment, as well as on the various WHO

policies that have influenced efforts to control cancer

Cancer control aims to reduce the incidence, morbidity and mortality

of cancer and to improve the quality of life of cancer patients in

a defined population, through the systematic implementation

of evidence-based interventions for prevention, early detection, diagnosis, treatment, and palliative care Comprehensive cancer control addresses the whole population, while seeking to respond

to the needs of the different subgroups at risk

Components of CanCer Control

Prevention of cancer, especially when integrated with the prevention of chronic diseases and other related problems (such

as reproductive health, hepatitis B immunization, HIV/AIDS, occupational and environmental health), offers the greatest public health potential and the most cost-effective long-term method of cancer control We now have sufficient knowledge to prevent around 40% of all cancers Most cancers are linked to tobacco use, unhealthy diet, or infectious agents (see Prevention module)

Early detection detects (or diagnoses) the disease at an early stage, when it has a high potential for cure (e.g cervical

or breast cancer) Interventions are available which permit the early detection and effective treatment of around one third of cases (see Early Detection module)

There are two strategies for early detection:

• early diagnosis, often involving the patient’s awareness of

early signs and symptoms, leading to a consultation with

a health provider – who then promptly refers the patient for confirmation of diagnosis and treatment;

• national or regional screening of asymptomatic and

apparently healthy individuals to detect pre-cancerous lesions or an early stage of cancer, and to arrange referral for diagnosis and treatment

iv

Planning

according to available resources and integrating cancer control with programmes for other chronic diseases and related problems.

Treatment aims to cure disease, prolong life, and improve

the quality of remaining life after the diagnosis of cancer is

confirmed by the appropriate available procedures The most

effective and efficient treatment is linked to early detection

programmes and follows evidence-based standards of care

Patients can benefit either by cure or by prolonged life, in cases

of cancers that although disseminated are highly responsive

to treatment, including acute leukaemia and lymphoma This

component also addresses rehabilitation aimed at improving the

quality of life of patients with impairments due to cancer (see

Diagnosis and Treatment module)

Palliative care meets the needs of all patients requiring relief

from symptoms, and the needs of patients and their families for

psychosocial and supportive care This is particularly true when

patients are in advanced stages and have a very low chance of

being cured, or when they are facing the terminal phase of the

disease Because of the emotional, spiritual, social and economic

consequences of cancer and its management, palliative care

services addressing the needs of patients and their families, from

the time of diagnosis, can improve quality of life and the ability

to cope effectively (see Palliative Care module)

Despite cancer being a global public health problem, many

governments have not yet included cancer control in their

health agendas There are competing health problems, and

interventions may be chosen in response to the demands of

interest groups, rather than in response to population needs or

on the basis of cost-effectiveness and affordability

Low-income and disadvantaged groups are generally more

exposed to avoidable cancer risk factors, such as environmental

carcinogens, tobacco use, alcohol abuse and infectious agents

These groups have less political influence, less access to health

services, and lack education that can empower them to make

decisions to protect and improve their own health

basic PrinciPles of cancer control

• Leadership to create clarity and unity of purpose, and to encourage team building, broad participation, ownership of the process, continuous learning and mutual recognition of efforts made.

• Involvement of stakeholders of all related sectors, and at all levels of the decision-making process, to enable active participation and commitment of key players for the benefit of the programme.

• Creation of partnerships to enhance effectiveness through mutually beneficial relationships, and build upon trust and complementary capacities of partners from different disciplines and sectors.

• Responding to the needs of people

at risk of developing cancer or already presenting with the disease, in order to meet their physical, psychosocial and spiritual needs across the full continuum

of care

• Decision-making based on evidence, social values and efficient and cost- effective use of resources that benefit the target population in a sustainable and equitable way

• Application of a systemic approach

by implementing a comprehensive programme with interrelated key components sharing the same goals and integrated with other related programmes and to the health system

• Seeking continuous improvement,

innovation and creativity to maximize performance and to address social and cultural diversity, as well as the needs and challenges presented by a changing environment.

• Adoption of a stepwise approach

to planning and implementing interventions, based on local considerations and needs (see next page for WHO stepwise framework for chronic diseases prevention and control,

as applied to cancer control).

Series overview

PlAnning sTeP 1

Where are we now?

cancer problem, and cancer control services or programmes

6

PlAnning sTeP 2

Where do we want to be?

defining the target population, setting goals and objectives, and deciding on priority interventions across the cancer continuum.

6

PlAnning sTeP 3

How do we get there?

implementation step 3

6 KEy mEssagEs 2

Assess the number of cancer patients in need of diagnosis and treatment 8 Assess the existing diagnosis and treatment plan and ongoing activities 10

PLaNNINg sTEP 2: WhERE do WE WaNT To bE? 16

Define the target population for diagnosis and treatment 16

Assess the feasibility of diagnostic and treatment interventions 17

KEy MESSAGES

The first module in the Cancer Control series, Planning,

provides a template for cancer control planning and progamme implementation The recommended framework draws on earlier WHO work in this field, the principles of

which are set out in National cancer control programmes,

policies and managerial guidelines (WHO, 2002), and

various WHO policies that have influenced cancer control

in the recent past

This module discusses how to plan and implement an effective diagnosis and treatment programme using a public health approach, within the context of a national cancer control programme It will be updated within the next 5 years as it is intended to evolve in response to new knowledge, evidence- based information, national needs and experience.

The key messages for people involved in planning cancer diagnosis and treatment services are as follows:

p The main goals of a diagnosis and treatment programme are to cure

or considerably prolong the life of cancer patients and to ensure the best possible quality of life to cancer survivors.

p Diagnosis and treatment services should initially target all patients presenting with curable tumours If more resources are available, the programme should be extended to include patients with the common cancers that are treatable but not curable.

p Effective diagnostic and treatment services use a multidisciplinary approach and are integrated into the existing health system Services are usually best developed at the secondary and tertiary levels as they are often costly, requiring specialized staff, infrastructure and procedures.

p Treatment involves not only managing all aspects of the cancer itself, but also the psychosocial and rehabilitation needs of the patients and their families Psychosocial support is particularly important because,

in many countries, cancer is greatly feared and stigmatized.

p Although the basic principles of cancer treatment are the same throughout the world, the specific treatment approaches adopted in each country should take into account cost-effectiveness, affordability, and social and ethical aspects Services should, however, always be provided in an equitable and sustainable manner.

p Health professionals caring for cancer patients need to be prepared to decide, in consultation with the patient, when therapeutic measures to cure or prolong life are no longer likely to be beneficial to the patient

and to institute palliative care instead (see Palliative care module).

Key messages

Cancer diagnosis comprises the various techniques and procedures used to detect or confirm the presence of cancer Diagnosis typically involves evaluation of the patient’s history, clinical examinations, review of laboratory test results and radiological data, and microscopic examination

of tissue samples obtained by biopsy or fine-needle aspiration

Cancer staging is the grouping of cases into broad categories based on the extent of disease, that is, how far the cancer has spread from the organ or site of origin (the primary site) Knowing the extent of disease (or stage) helps the physician determine the most appropriate treatment to either effect a cure, decrease the tumour burden, or relieve symptoms “Early cancer” refers to stages I and II “Advanced cancer” refers to stages III and IV Stage

of disease at diagnosis is generally the most important factor determining the survival of cancer patients The duration of survival is widely used as a measure of the effectiveness of the treatment of cancer.

Cancer treatment is the series of interventions, including psychosocial support, surgery, radiotherapy, chemotherapy and hormone therapy, that

is aimed at curing the disease or prolonging the patient’s life considerably (for several years) while improving the patient’s quality of life.

Cancer management involves cancer staging and treatment Cancer management starts from the moment the patient’s diagnosis of cancer

is confirmed

key definitions

Cancer survivors are those patients who having had cancer are, following treatment, now cured of the disease Cure is defined as the attainment of normal life expectancy and has three important components:

p recovery from all evidence of disease (complete remission);

p attainment of a stage of minimal or no risk of recurrence or relapse;

p restoration of functional health (physical, developmental and psychosocial)

high potential for being disease free in the 10 years following cessation of treatment, such that the patient may eventually die of another condition Curable cancers include:

p cancers that can be detected early and effectively treated;

p cancers that although disseminated or not amenable to early detection methods, have a high potential for being cured with appropriate treatment.

Cancers that are treatable but not curable are cancers for which treatment can prolong life considerably (for several years) by temporarily stopping or slowing down the progression of the disease.

Key messages

It is estimated that, worldwide, there are millions of cancer patients with curable cancers With early detection, timely diagnosis and adequate treatment, carried out within the context of a comprehensive cancer control plan, the lives

of a significant number of cancer patients can be saved or prolonged considerably

Is a NEW caNcEr dIagNosIs aNd trEatmENt plaN NEEdEd?

There is no country in the world where cancer does not occur Curative treatment exists for about one third of all cancer cases, but particularly breast, cervical and oral cancers, provided they are detected early Some cancers, such as metastatic seminoma, and acute leukaemia and lymphomas in children, although disseminated or not amenable to early detection methods, have high potential for being cured Patients suffering from these types of cancers can be diagnosed and treated with interventions that are affordable, even in low-income countries

Unfortunately, in many countries, particularly low-income countries, diagnostic and treatment services are not planned rationally Treatment technologies and infrastructure are not linked

to early detection strategies, and there is usually an excessive reliance on costly procedures that serve mainly the wealthy who can afford them Consequently, a high proportion of patients having cancers that are curable if detected early are diagnosed in advanced stages, at which point a small number receive costly, but ineffective and incomplete treatment In such settings, the same resources would be better employed, and would benefit a greater number of patients,

if they were to be used to fund low-cost palliative care (see Early detection and Palliative care

modules)

The development of good quality diagnostic and treatment services to address curable cancers

is therefore imperative, especially in the great majority of low-income countries This would help

to save lives, avoid unnecessary suffering and make more efficient use of limited resources

her story dIagNosEd WITh aCuTE

LymPhobLasTIC LEuKaEmIa

aT ThE agE of 12 yEaRs,

LaLITa Is NoW dIsEasE fREE

aNd LooKs To ThE fuTuRE

WITh oPTImIsm aNd hoPE

Eulalia Maria Vásquez Rivera (Lalita) is originally from Tegucigalpa, Honduras, and is the fourth daughter in a low-income family She has six brothers and sisters Lalita was experiencing bone pain, permanent fever, weight loss and bleeding gums She remembers what happened during hurricane Mitch, when her parents took her to Escuela Hospital, the main teaching hospital in the public health system At 12 years of age, in the Paediatric Haemato-oncology Unit, she was diagnosed with acute lymphoblastic leukaemia Lalita started chemotherapy treatment in November

2001 and successfully completed it at the end of August 2004 She has been free of the disease for

3 years She is now 17 years old and very happy One of her dreams used to be to become an interior decorator, but now she would like to become a nurse Lalita says, “Suffering from cancer has taught me

to enjoy life immensely Whatever I undertake, I will achieve through faith in God and in myself.”

Lalita is but one of the 500 children who have been diagnosed and treated for acute lymphoblastic leukaemia in the past 7 years at the Paediatric Haemato-oncology Unit of the Escuela Hospital The Unit is open to all children who suffer from leukaemia

or other types of cancer For patients from low-income families, the cost of treatment is covered by the public health system, with the assistance of the Honduran Foundation for Children with Cancer Assistance from the latter is generally in the form of provision

of chemotherapy drugs, special laboratory tests, and psychosocial support for patients and their families Honduras is a low-income country facing numerous economic and social challenges However,

thanks to a well-organized programme for the treatment of childhood cancer, great progress has been made Today, around 60% of children with acute lymphoblastic leukaemia can be cured using standardized protocols for treatment and comprehensive care.

Source: Information provided by Dr Ligia Fu Carrasco, Paediatric Haemato-oncology Unit, Escuela Hospital, Tegucigalpa, Honduras Further information on the work that has been done to fight childhood cancer in Honduras, including the efforts of the civil community, can be found at http://www.salvamivida.org.

Pre-planning

PlANNING STEP 1

Where are we now?

The Planning module provides an overview of what to

assess in relation to the overall cancer needs in the general population, the groups particularly at risk, and the existing plan and services for responding to those needs This

Diagnosis and treatment module provides more detailed

information on how to assess the number of people in need

of diagnosis and treatment, and the existing diagnostic and treatment policies and services

assEss tHE NUmBEr oF caNcEr patIENts IN NEEd oF dIagNosIs aNd trEatmENt

By assessing the number of people with curable cancers or cancers that are treatable but not curable, it is possible to estimate the number of patients who could benefit most from timely and adequate diagnostic and treatment services

Performing such an assessment will provide responses to the following key questions:

p Which are the most common cancer types that have high potential for being detected early and cured?

p Which are the most frequent cancer types that, although disseminated or not amenable

to early detection, have a high potential for being cured?

p Which are the most frequent cancer types that are treatable but not curable?

p What proportion of all paediatric cancers are curable?

p What proportion of all paediatric cancers are treatable but not curable?

Table 1 The burden of curable cancers and cancers that are

treatable but not curable: what to assess

Cancers that are curable when detected early

All curable cancers

Cancers that are treatable but not curable

Advanced breast cancer

Advanced cutaneous melanoma

Advanced Hodgkin lymphoma

Advanced non-Hodgkin lymphoma

For each common cancer type with a high potential for cure or for which treatment may

prolong the patient’s life considerably (for several years), it is important to determine the age,

sex and geographical disparities in incidence, stage distribution, mortality and survival

Table 1 provides a template for organizing the data obtained by the disease burden assessment

and thereby identifying the most common types of curable cancers and cancers that are

treatable but not curable The necessary data can be derived according to the approaches

described in the Planning module (see planning step 1, pages 14–15)

Planning step 1

trEatmENt plaN aNd oNgoINg actIVItIEs

In assessing the existing diagnosis and treatment plan and ongoing activities, it is important

to recognize that diagnosis and treatment together constitute a complex component of overall cancer control which, in an ideal scenario at least, is closely allied to early detection and palliative care activities Cancer diagnosis and treatment services are mainly available

at the secondary and tertiary levels, and are usually provided by professionals from a great variety of disciplines and specialties

Table 2 shows what to assess regarding the existing cancer diagnosis and treatment plan

and ongoing activities These aspects are discussed in more detail in the Planning module

The initial focus should be on the gap between what is needed to provide services to the population with curable cancers, and what is currently available

Table 2 The diagnosis and treatment plan and related activities: what to assess

Plan and activities What to assess

Diagnosis and treatment

plan •• Endorsement of the plan and its scope (geographical area and cancer types included) Whether or not part of a comprehensive cancer control plan

• Timeliness (updated/outdated)

• Accessibility to the written plan

• Stakeholders’ involvement in plan development

• Inclusion of critical sections of the plan (assessments, goals and objectives, strategies, timetable, responsible persons, resources, monitoring and evaluation)

• Priorities (objectives and actions related to diagnosis and treatment of curable cancers)

• Integration with the plan for noncommunicable diseases and other related problems

• Utility of the plan (used to guide programme implementation)

Ongoing diagnosis and

treatment services •

Number and coverage of diagnosis and treatment interventions and related services offered (including patient education, psychosocial support, symptom management, home care, etc.)

• Quality of ongoing diagnosis and treatment activities

• Integration with ongoing services for noncommunicable diseases and other related problems

• Evaluation of outcomes, output and process indicators, and trends

• Protocols, guidelines, manuals, educational materials, etc.

• Physical resources (infrastructure, technologies, essential list of chemotherapy drugs)

• Human resources (leaders, councils, committees, health-care networks, health-care providers, partners, traditional healers)

• Financial resources

• Regulations and legislation

Context of the diagnosis • SWOT analysis: strengths, weaknesses, opportunities and threats concerning the

Ask the following questions to assess the existing diagnosis and treatment service

provision:

WHAT DIAGNOSIS AND TREATMENT SERvICES ARE AvAIlAblE?

p Are there diagnosis and treatment services for curable tumours? How are they

organized?

p Are the diagnosis and treatment services linked to early detection programmes?

p Are the diagnosis and treatment services linked to palliative care?

p What is the target population for the diagnosis and treatment programme? Does it

explicitly include adults and children?

p What diagnostic tests are recommended to confirm the diagnosis of specific types of

curable cancers and of other common cancers that are treatable but not curable?

p Are there clinical guidelines for the treatment of the curable cancers?

p Are there clinical guidelines for the treatment of the cancers that are treatable but not

curable?

p Are there guidelines for the provision of patient information and support?

p Are there guidelines for organizing treatment services for curable tumours?

p Are there guidelines for organizing treatment services for the cancers that are treatable

but not curable?

p Do the organizational guidelines define the roles and functions of health-care providers

at the different levels of care?

p Are there systems to ensure regular monitoring and evaluation?

p Do the monitoring and evaluation systems include adequate quality control of the

diagnostic, treatment and follow-up methods?

HOW WEll ARE DIAGNOSIS AND TREATMENT PROGRAMMES DOING? HAvE

MEASuRES Of SERvICE DElIvERy quAlITy bEEN IDENTIfIED AND ARE THEy

MONITORED REGulARly?

Quality can either be assessed through a system model of inputs, processes, outputs and

outcomes (short-, medium- and long-term) or by adopting a continuous quality improvement

framework, composed of a number of quality dimensions that can be explored through

questions such as the ones listed below:

p Are all the diagnostic and treatment services accessible (ensuring coverage and

timeliness) to the target population?

p Are the services acceptable (ensuring providers’ and patients’ satisfaction) and

appropriate (based on established standards) for the target groups?

p Are the competencies (knowledge and skills) of the providers appropriate for the

services needed?

p Is there continuity (integration, coordination and ease of navigation) in the activities of

the diagnosis and treatment programme?

p Are the diagnostic and treatment services safe for providers, patients and the

environment?

p Are the diagnostic and treatment services effective (in terms of cure or improved

Planning step 1

p improved quality of life for cancer survivors;

p decreased mortality among patients with the targeted cancer types

ASSESSING THE EffICIENCy Of DIAGNOSIS AND TREATMENT PROGRAMMES

Diagnosis and treatment programmes can achieve very different results with the same level

of resources Programmes are particularly efficient if they target curable cancers.

It is unfortunately not rare, in low-resource settings, to see a local government investing

in hugely expensive cancer treatments, such as bone marrow transplant units Only a few very high-income patients will be able to afford such costly treatment, and their chances of survival will be low The same level resources could, however, be used to treat hundreds of children, including those from low-income families, who have acute lymphatic leukaemia, for which cure rates are potentially over 80%

Relevant questions to ask in order to assess the efficiency of diagnosis and treatment programmes are shown in Table 3

ASSESSING PATIENT SAfETy IN DIAGNOSIS AND TREATMENT PROGRAMMES

Patient safety is achieved by avoiding, preventing or ameliorating adverse outcomes or injuries stemming from the processes of health care (WHO, 2005) In the United States of America, the National Cancer Institute has recommended common terminology for reporting adverse events, applicable to all oncology clinical trials regardless of chronicity of adverse events or modality of treatment This terminology is useful in assessing the safety of all health-care interventions (National Cancer Institute, 2003)

To assess whether a diagnosis and treatment component is safe in a country or region, it is useful to pose the following questions:

HOW MANy PATIENTS PER yEAR ExPERIENCE MEDICAl ERRORS OR SuffER INjuRIES ASSOCIATED WITH THE DElIvERy Of DIAGNOSIS AND TREATMENT PROCEDuRES?

Table 3 Questions to help assess the efficiency of cancer

diagnosis and treatment programmes

Efficiency measure Basic question(s) Examples of specific questions relating to diagnosis and treatment programmes: the answer “yes” means that the programme is efficient

• Is the treatment programme directed at the right target groups? For example,

is the programme directed at patients with early stages of cancer, rather than those with advanced cancer?

• Is the amount of over-treatment insignificant? For example, are recommended conservative procedures, rather than more invasive ones, used to treat cervical cancer in-situ?

• Are staff adequately trained and do they perform well?

• Is there adequate equipment for optimal diagnosis and treatment?

• Are facilities and supplies being fully used?

• Are we using all available information?

• Are we helping patients to adhere to their treatment and care regimes? For example, are we educating patients about their disease and treatment, and empowering them to cope effectively?

Productive efficiency

(choosing different

combinations of

resources to achieve

the maximum health

benefit for a given

cost)

Could we improve the health outcome for a given cost?

• Have we reallocated the available diagnostic and treatment resources, and targeted patients with curable cancers, to obtain better outcomes?

• Have we redistributed the diagnostic and treatment resources to underserved groups within the target population?

• Do we complete the diagnostic, treatment and follow-up protocol in patients with early symptoms of cancer?

• Do we maintain and develop the performance of health workers?

• Do we maintain a level of workload that is between the minimum and maximum standards?

• Do we maintain adequate standards of diagnostic and treatment service provision through quality assurance?

• Do we provide appropriate advice and counselling for patients and their families to help them cope with their situation?

Could we reduce costs for a given outcome?

Based on the evidence, are we using the most cost-effective:

• early detection tests?

• definitive diagnostic tests?

• treatment options?

• follow-up options?

• health workers?

• strategies to identify those at high risk for emotional distress?

• strategies to empower the target groups to take more responsibility for their own decisions?

• strategies to reach the target groups?

• strategies to reach patients with abnormal results and refer them for further investigations?

• strategies to follow up patients who have been treated?

• strategies to improve the performance of health workers?

• strategies for quality control?

• Do we choose the most cost-effective and affordable diagnosis and treatment interventions for the population?

• Do we choose the most cost-effective and affordable cancer prevention and palliative care interventions for the population?

Planning step 1

p Is there a system to identify medical errors and causes of patient injury?

p Are practices being implemented that eliminate medical errors and systems-related risks and hazards?

ASSESSING CuSTOMER SATISfACTION WITH DIAGNOSIS AND TREATMENT SERvICES

Customer satisfaction is the state of mind that customers (patients and their families) have

when their expectations have been met or exceeded Customer satisfaction is subjective

To establish whether a diagnosis and treatment programme for cancer is producing customer satisfaction, it is useful to ask the following questions:

p Do patients comply with treatment and follow-up?

p Is customer satisfaction improving over time?

p How many formal complaints have been received?

p What are customers’ expectations, preferences, needs and requirements?

p Are the services designed to meet customers’ expectations, preferences, needs and requirements?

assEss tHE socIal coNtEXt

The development of a diagnosis and treatment plan and programme requires a thorough understanding of the context The integration of social context with the diagnosis and treatment plan will considerably enhance acceptance of the plan, both politically and socially One way to do this is through an analysis of the strengths, weaknesses, opportunities and threats (SWOT analysis) of the existing plan and related activities.

During the course of a SWOT analysis, the following questions should be answered:

WHAT ARE THE STRENGTHS AND WEAKNESSES ASSOCIATED WITH PlAN DEvElOPMENT AND IMPlEMENTATION?

These are factors affected by internal forces, such as political support, leadership, stakeholders’ involvement and resources available For example, politicians and decision-makers are usually supportive of treatment services for cancer but they do not prioritize

www i

For more information on patient safety, go to

http://www.who.int/patientsafety/reporting_and_learning/en/

WHAT ARE THE OPPORTuNITIES AND THREATS ASSOCIATED WITH PlAN

DEvElOPMENT AND IMPlEMENTATION?

These are factors affected by external forces, such as the international cancer control agenda,

the political and economic situation within the country, and the existence of other pressing

health priorities For example, the fact that WHO and its international partners are promoting

a balanced approach to cancer control interventions – from prevention to end-of-life

care – represents an opportunity to advocate for the development of more effective and

efficient national policies for diagnosis and treatment

sElF-assEssmENt BY coUNtrIEs

WHO has developed a set of self-assessment tools for assessing, at different levels of

complexity, the population cancer needs and existing services A description of the tools can

be found in the Planning module.

self-assessment tools, which can be adapted to country

circumstances, are available from the WHo web site

http://www.who.int/cancer/modules/en/index.html

the WHo web site also provides links to sources

containing more specific tools for assessing the needs

and existing services for diagnosis and treatment of cancer

www i

For further information, including details of

international organizations working in cancer

diagnosis and treatment, go to

http://www.who.int/cancer/modules/en/index.html www i

Planning step 1

PlANNING STEP 2

Where do we want to be?

The assessment exercise described in the previous section ( planning step 1) aims to identify the gaps in services,

as well as in data and knowledge, with regard to the burden

of curable cancers and cancers that are treatable but not curable.

The next step is to consider what could be done, given limited

resources and capacity, in order to answer the question: Where do we want to be?

dEFINE tHE targEt popUlatIoN For dIagNosIs aNd trEatmENt

The selection of the target population for a diagnosis and treatment plan depends on the burden of curable cancers and cancers that are treatable but not curable

In the case of curable cancers, the target population will be the following:

p all patients of a certain age group and sex in which an abnormality indicative of cancer has been detected through an early detection examination or test, or by chance during

a routine examination;

p all patients, particularly children, that present with signs and symptoms of a cancer that has a high potential for being cured

In the case of cancers that are treatable but not curable, the target population will be all

patients who present with cancers and who could benefit from treatment because they could

IdENtIFY gaps IN dIagNostIc aNd

trEatmENt sErVIcEs

Using the results of the assessment, the gaps in diagnosis and treatment service provision

can be identified (present state versus desired state) and potential corrective interventions

considered For example, if, as is often the case in resource-constrained countries, the

majority of cervical cancer patients are presenting in advanced stages, the introduction of

a well-organized early detection programme coupled with timely diagnosis and treatment

could eventually have a significant impact on survival rates and thus reduce substantially

the mortality from cervical cancer

It is important to assess the impact of diagnosis and treatment interventions previously

implemented in the target population, and also of those that have been successfully applied

elsewhere, particularly in similar socioeconomic and cultural settings

sEt oBJEctIVEs For dIagNostIc aNd

trEatmENt sErVIcEs

The objectives of diagnostic and treatment services should respond to the needs of people

who have curable cancers or cancers that are treatable but not curable The objectives should

be directly related to the identified gaps in services For a diagnosis and treatment plan to be

effective, all process and outcome objectives need to promote the common goal of improving

survival and reducing mortality among the targeted population

Table 4 provides examples of short-, medium- and long-term process and outcome objectives

for diagnosis and treatment, according to the level of resources

assEss tHE FEasIBIlItY oF dIagNostIc aNd

trEatmENt INtErVENtIoNs

The feasibility of diagnosis and treatment interventions in a given population depends on the

skills and infrastructure available, the knowledge and attitudes of the target population, and

the motivation of the government and health-care providers

For a diagnosis and treatment programme to be effective, it should target people with curable

cancers, and it should deliver good quality services (early detection, diagnosis, treatment

and follow-up) equitably – usually for an indefinite duration – to all members of the target

population

For decades some resource-constrained countries, where a high proportion of patients present

with cancers in advanced stages, have invested in costly and often ineffective treatments

which serve relatively few patients As a consequence, there has been no improvement

Planning step 2